Richard Taite

Can Alcoholics Ever Drink Moderately?

Moderate drinking may not be possible for alcoholics.

When you’re sober, it’s so easy to tell yourself you’ll have just one drink. Or if you’re trying to be honest with yourself, you say you’ll stop at two; maybe two is enough to feel it, but not enough to have any consequences. But what happens when you finish that second drink? How do your sober intentions hold up against the reality of that buzz waiting just inside the fridge or on the shelf? In short, can you really stop at one or two or does that one drink wreck any willpower you had earlier in the evening until you finish the rest of the alcohol in the house...and go looking for more?

This question is the backbone of a major debate in addiction research and treatment: can people addicted to alcohol go back to moderate drinking? For years, the answer was assumed to be an unequivocal no: programs based on the 12-Step models dominated treatment and there is no room for “just one drink” in AA.

But now these traditional programs are being influenced by modern research to create new and sometimes very much improved strategies of addiction treatment. We are questioning everything and in the process we’re discovering what works and what doesn’t. This reexamination of the truths we once thought absolute opens the debate on moderation.

So which is it? Is the 12-Step-based model of absolute abstinence still scientifically accurate or does the “moderation management” approach championed by ModerateDrinking.com and elsewhere have a place in modern addiction care?

The answer comes down to what kind of drinker you are – why do you drink, how much do you drink, and how long have you been in this pattern? That’s because the longer you have been in an aggressive drinking pattern, the more your consumption changes the physical characteristics of your brain.

“Problem drinkers” may still be purely motivated by emotion or association or coping or opinions about alcohol’s desirable effects. In other words, their drinking may have a purely cognitive cause. There’s fairly strong evidence these “non-dependent problem drinkers” can retreat from addiction into moderate drinking. For example, this clinical trial by the major proponent of moderate drinking, Dr. Reid Hester, shows that even among non-addicted problem drinkers, lighter drinkers benefit more than heavy drinkers from moderation management.

But there seems to be a tipping point after which problem drinkers can no longer moderate their drinking.

When problem drinking becomes addiction, cognitive causes aren’t the only reasons to drink. Instead, long-term dependence on alcohol creates changes to the physiology of the brain, resulting in complications like memory loss and even stunting the brain’s ability to grow new neurons. Over time, a brain chronically exposed to alcohol also loses its ability to produce and use dopamine, one of the main chemicals that makes humans feel “good” or euphoric. The addicted brain is addicted. And it’s not one or two drinks the addicted brain wants.

Writing in the journal Psychiatric Services, Dr. Keith Humphreys makes a similar point, showing that, “The vast majority of Moderation Management members have low-severity alcohol problems, high social stability, and little interest in abstinence-oriented interventions.” In this setting of low-severity problems, moderation management has shown to be moderately effective and in Humphrey’s opinion, “the inclusion of MM in the array of options for people attempting to resolve drinking problems seems on balance a benefit to public health.”

But Humphrey joins almost all reasonable researchers in the field of addiction, agreeing there is a huge difference between the brain of a non-dependent problem drinker and the brain of a person addicted to alcohol. For these addicted brains, the only real option remains abstinence. One drink gives the brain the leverage it needs to force the addicted person into many.

During April’s Alcohol Awareness Month, I hope you’ll join me in the real, inward-looking experience of discovering what kind of drinker you are. If the answer is “non-dependent” you may have the choice of moderation management. But if the answer is alcoholism, your best goal has been and remains abstinence.

in the case of alcohol use, a nationally representative survey of 43,000 adults (http://www.spectrum.niaaa.nih.gov/features/alcoholism.aspx, summarized at http://www.medscape.com/viewarticle/703483) funded by NIAAA concluded the following:

“Twenty years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.”

“About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.”

***

The norm is that problem drinkers stop on their own, and more than half of those who stop, drink at low-risk levels afterward. This should give big hope to many problem drinkers.

I quit on my own. I had a spontaneous recovery a little over 3 years ago. It wasn't really spectacular, noting really happened. I just didn't drink. I did not make any public declaration of my intent to quit. I didn't go to a meeting. (I am a solitary person so social people may benefit from groups when looking for new things to do)

There is an NIAAA study that says approximately 24% of drinker quit this way. (It looks like they did another study, this study I mention was in 2005, I think).

I have not tried to drink moderately. But if I drank a someone else's soda that had alcohol in it by accident, I would not run to the nearest AA meeting or anywhere else. I also have not had a slip or a relapse.

Once I felt that alcohol was bad for me I was done. Knowing alcohol was bad for me didn't get me to stop. I had to feel it.

"The addicted brain is addicted. And it’s not one or two drinks the addicted brain wants."

This statement suggests humans can't change and alcoholism is an incurable disease. All change ultimately occurs because of decisions (THINKING) people make for themselves. People change with they are HURT enough and HAVE to, or when the LEARN enough and WANT to.

People overcome addiction out of purpose-based motivation -- they quit when they recognize how their habit violates WHO they were, WHAT they want to be, WHERE they want to go in life. A person's purpose and values are the main navigational tools in recovery from any hurt, habit or hang-up.

People are not mindless experimental rats lacking free will (disease model).

Granted there are people who don't give a hoot (no purpose driven motivation) and will always drink to excess.

Complete abstinence for some is necessary but these folks can be filtered with motivational interviewing and psychotherapy that you won't find at AA backed dogma groups.

Mid 30s drunk decided he was going nowhere and he was an ass while drunk. Got his life together, drank still but never to the point of drunk.
I also know several that quit but are still addicts... they just drink insane amounts of coffee.

The main thread is to find the difference between "problem drinking" and "alcoholism" -- which unfortunately in most studies are lumped together as "alcohol dependence." Many people are problem drinkers. Some of those might even "look" to the outsider like an alcoholic. Take the young man or woman in college who parties three or more days a week. S/he might find him/herself experiencing blackouts, unable to go to class at times because s/he is too hungover, shaking a little when s/he stops drinking, having sexual contacts that are regretted later, etc. We'd consider these the actions at least of a problem drinker, if not an alcoholic. Yet the greatest majority of these young people leave college and immediately clean up when they get a job and other forms of responsibility. On the alcohol use spectrum, we would consider these individuals heavy or problem drinkers. They may have some negative consequences to their drinking, but still have the ability to change their ways unaided. These individuals will likely be able to drink moderately if they choose to. These individuals also are not good candidates for treatment. If you can relatively easily make changes to your lifestyle on your own, changes that stick, I applaud you.

The true alcoholic, different from the heavy or problem drinker, has both a biochemical and a physical change to his/her brain. The consequences of their drinking become increasingly severe over time. They try to quit and are unable to do so without help. In these individuals, the brain is essentially co-opted by addiction to the point that the individual literally can no longer make good decisions for him/herself. There's some good research from McGill University on this phenomenon if you're interested.

No, the vast majority of people who fall into the category of alcoholic -- this second group -- never seek treatment. It is also true that while many addicts in recovery have a soft spot for 12 step programs, they have a very poor recovery rate when used on their own -- 10% or less at one year. Whereas addicts who go through an evidence-based treatment program for three to four months and then complete an aftercare program at home for another eight or nine months (which will likely include but not be limited to 12 step meetings), those individuals recover at a rate of about 70% or more...again, for those who do ALL the suggested work in their treatment and aftercare programs.

What happens in treatment and aftercare that makes these individuals successful? In essence, we are able to rewire or retrain the brain to allow recovery to occur. Think of it this way -- if addiction is a feedback loop that prevents good decision making, in recovery, we create a new feedback loop that circumvents the damaged parts of the brain and allows a new lifestyle to develop. The old addiction feedback loop is still there, hence the reason for abstaining from drinking for these individuals -- but a new life...and in some ways, a new brain -- a new vision for seeing the world -- comes from treatment.

Thank you for this. I used to drink a large amount for a few years in my 20s. I stopped drinking altogether for about 10 years but enjoy a beer or two on occasion these days.
I had been told that I was likely an alcoholic and should never drink again in the past. I have no desire to return to being a drunk but I've worried that maybe they were correct. To me a distinction between problem drinker and alcoholic makes sense. I've admitted I drank far too much then but it always felt it was a choice for me and not a need. Though I had wondered if I was just lying to myself.

1. Why is a problem drinker not a good candidate for your treatment, but an actual alcoholic is one?

2. Are you really saying that if you opened up the brains of a problem drinker at the three year mark of problem drinking, and the brains of an alcoholic at the three year mark of alcoholism, those brains would look different? Any studies to back this up? I can accept that you can retrain a brain to allow recovery to occur. That's what the CBT and DBT therapists do. But "rewire?" That would require the brains to look different even while the drinking is going on, and I have seen nothing to support that.

The entire disease model is primarily based on mammalian rat studies that are extrapolated to human beings. I'm not saying this is bad or unworthy, but just realize the profound limitations in variable control.

Then again, I may be ignorant of a special breed of rats, with free will, choice and reason.

I believe our brain changes, but I believe my brain was also changed by reading this article. Dendrites proliferate whenever we learn something.
If the area that is creating the addiction for us is larger or better wired or more dense; what other functions might the area perform. Instead of trying to get rid of it can it be re-purposed.
What areas are affected most significantly.

I have had lifelong depression. Can I now use the no longer needed drunk part of my brain and use it to be happy?

In fact, there are many studies showing that the brains of "problem drinkers" are different than the brains of "alcoholics" or at least showing that the more you drink, the more the structure of your brain is affected. For example:

• http://psycnet.apa.org/psycinfo/1983-32942-001 -- "Alcoholics had larger ventricles, wider cerebral sulci, and wider Sylvian and interhemispheric fissures. Subjects whose scans had improved at follow-up differed from the rest with regard to length of abstinence prior to rescanning."
• http://psycnet.apa.org/psycinfo/2004-10881-018 -- "This study suggests, as did our earlier study, that alcoholics and not heavy social drinkers, when exposed to alcohol cues, have increased brain activity in areas that reportedly subserve craving for other addictive substances.
• http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.1988.tb00137.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false -- "Across the entire group, alcoholics had significantly enlarged ventricles and sulci for their age. Enlargement at both sites correlated significantly with lifetime alcohol consumption."

These and many more show that if you opened up the brain of a problem drinker and an alcoholic at the three-year mark, the brains would look different. Interestingly, a couple of the studies cited above show the results of follow-up scanning in which after a period of abstinence, the brain does literally "rewire" itself back toward normal structures.

I find it very interesting to find that there is another component to consider when discussing the brain's ability to literally "rewire" itself. The component being the length of time the brain has been recovering. I may be an example of this. I went through treatment in 1980 and had been in recovery for 32 years when I read the same studies you quoted above. I decided to experiment and started drinking wine several evenings each week for the past 2 years. I have not experienced any urges to go back to heavy drinking and seems to support the above findings. I am wondering why this extra component has not been researched further. I think a lot of alcoholics would like to know that their brains, after many years of not drinking, may have repaired themselves and it may be possible to social drink.

substitution.
Seem like there is big hope with this.
For me its not alcohol. never loved the stuff fully. For Mr its lean meats. I searched for substitutes. found out I liked fish way much better.
Health benefits have been great.

1. Problem drinkers, individuals who drink to excess once in awhile or even reasonably frequently, but who are not alcoholic are not good candidates for any treatment center. Any problem should be addressed with the lowest level of care we can reasonably expect to work. Someone who overindulges now and again will do well in psychotherapy or out-patient treatment. Alcoholics, individuals who literally cannot go without drinking for more than a very brief period of time first of all need a supervised medical detox, because a person can die from alcohol withdrawal. Second, they need a higher level of care in which they are able to get a foundation for recovery before they are returned to an environment in which temptation to relapse abounds. There are not enough treatment beds even for those who need them. Let's be sure that those beds go to those who are most in need. Those who can reasonably be expected to be able to change their habits without residential treatment should be encouraged to do so.

This is different than expecting someone to fail out of treatment in order to "earn" a place in a higher level of care. Treatment professionals are adept at discerning what level of care is best suited to an individual he/she is working with. A trusted professional should be able to tell you honestly what level of care you or your loved one requires.

2. Your second question is about neuroscience research. For this, I defer to my full time addiction researcher, Dr. Constance Scharff. Over the course of the last year, Dr. Scharff has shared with me numerous studies coming out of universities in Canada, the United States and across Europe indicating that yes, not only does the biochemistry of the brain change in response to both addiction and recovery, but so too does the physical structure of the brain. As she explains it, the brain is far more dynamic than we previously thought and yes, it changes its structure in addition to its chemistry based on behaviors we do over and over again. This is very leading edge stuff, but yes, the science now seems to indicate that the brain changes are physical. Fascinating stuff!

Quick background: I've been in 5 treatment centers in my life, suffered from an eating disorder and was physically addicted to benzodiazepines. I drank quite heavily and could never control it once I started. Fast forward - 27 years later - 18 spent in recovery with no relapses - and guess what? I can drink - quite normally I may add and have been doing so for years. I have never been 'drunk' during that time. I have never drank more than one drink and I have absolutely no desire to do so. I have taken benzodiazepines on occasion for back issues. I had one prescription of 20 - it's been four years and there are still pills in the bottle. I am free from any kind of obsession regarding alcohol or my medicinal use of drugs including pain killers which were required short term for two surgeries. My eating disorder has also remained in re-mission. I can eat any kind of food I please and I am a normal weight. The thing is, I don't think I'm special, I think that over the years my brain has rewired itself. Specifically, I rewired it without knowing I was doing so. Was I an addict and an alcoholic? Any of the treatment centers I entered would tell you yes. I had to be medically withdrawn from benzodiazepines and I would drink until I blacked out every time. I think the brain is quite plastic. I don't know of any other way to explain myself. I have not attended a 12 step meeting in ages and my life is quite normal.

What the science is currently showing us is that once the brain has developed this addicted pattern, that is once it has changed its structure, that part of the brain never changes back. Even if the person stops drinking, the new neuron pathways have been made and that's that.

In recovery, and this research is still preliminary, it looks as if the brain rewires itself around the "addict" part, circumventing it.

If the addict does not go back to using, the addict neural pathways will remain dormant. If the addict returns to using, the brain will be triggered and the addict will pick up just where s/he left off, with tragic results -- consider Philip Seymour Hoffman as an example.

>>What the science is currently showing us is that once the brain has developed this addicted pattern, that is once it has changed its structure, that part of the brain never changes back. Even if the person stops drinking, the new neuron pathways have been made and that's that.

Mr. Taite, I think you're missing the point. When I ask about the difference in brains between a problem drinker and an alcoholic, I'm asking about those brains during a time when they are consuming the same amount of alcohol! Are you are seriously saying that a problem drinker after three years of daily eight drinks, and an alcoholic after three years of daily eight drinks, will have different-looking brains? Where's the study to support that? No one is doubting that a heavy drinker and a person who drinks twice a week will have different-looking brains. The doubt is about the difference in brains between alcoholics and problems drinkers in the midst of their drinking.

And how do you explains, "How do you explain me?" post above? Is addiction the one brain disease in the history of science where motivation alone can "rewire" the pathways? Really?

This is a thin line to walk. I understand that research is being presented that recovering alcoholics may be able to return to moderate drinking, but that is something I am not sure individuals who are in recovery need to even consider. Willpower can only be so strong. It can be very difficult to determine how for you will go after just one drink. I would like to hear a testimony from an individual who has overcome their addiction and is able to moderately or socially drink. Thanks for the topic, very good discussion.

Moderation is possible for many but not for all. It all depends on the individual relationship with their inner self, maturity, values and global purpose in life. The question becomes how do you respond to stress? Do you exercise a displaced behavior in order to regain control of your stressful situation or do you NOW have the ability to produce a healthy direct response in order to regain control of your circumstances and life.

You can read more here. http://christrecovery.discussioncommunity.com/

Does the brain rewire itself? Do you pull the triggar if you take one drink? These questions seem to abound such forums as this.I became alcohol dependent after drinking to block out painful emotions,alcohol really worked for this! I stopped for a few weeks then started again,back to square one! This time I moderated and drank successfully for a few months,but upon the death of a relative,and my poor coping mechanisms it got worse,proving I couldnt control my withdrawels not cravings? I didnt want to drink but the withdrawels were toi painful for me,fast forward to Christmas 2013 I had a fast detox on librium followed by a 12 step rehab.....This i struggled with as even now I dont agree with the AA higher power or 12 step religious(in my view) recovery model.I reckon time away from ny surroundings and a long period of abstinence has allowed my brain to reset,I drank for 6 months to quite a large amount including the dreaded vodka,whisky n wine,with no consequences apart from feeling rough(as normal drinkers do) and no cravings apart from a pint after work on a sunny day!
Why take the risk you may ask? For me the not knowing was too much,I felt normal after the first month in rehab but didnt drink for almost a year,and I also knew I could do a diazepam detox as soon as I felt ill,not ideal but fact,so where now? The attraction of alcohol isnt there,knowing I can takes the power out of it (recovery phrase) Am I special? Doubt it....

So, I'm confused. If I was severely addicted to alcohol (started drinking at 13, 1/3-1/2 handle a night by 17, DTs by 18, multiple medical detoxes, got clean at 20), and have had two years clean with the help of a 12 step fellowship, is my brain still in that category of being changed so I couldn't dirnk moderately or has the time away allowed my brain to heal, so that maybe I could?

I was sober for over 20 years. 2 years into my divorce I was finally starting to face the reality of my situation - that my wife was gone and how much of my identity was wrapped up in being her husband and supporter. I have not felt this worthless or lonely in a long long time, and I just felt that I have really nowhere to go. Life now just seems very bleak and the financial and emotional strain of divorce wore me down. I started drinking again 2 months ago, and I drink almost every day. Some days I only have 6 or 8 drinks, but when I "go out" on weekends I will drink 15 or more drinks. I really didn't intend to drink this much - I really started drinking again because I didn't have any social outlets and I wanted to meet people and enjoy myself, but I wound up going to bars and pubs to meet people like I did a long time ago. The trouble is, too, that in addition to the health, social and vocational dangers I simply cannot afford to spend hundreds of dollars every week in the pub. I figure I will be $12 - $15K in debt by the end of next year if I don't reduce my alcohol consumption or eliminate drinking again entirely. I think I need to quit entirely. I wish I didn't choose to drink again (and it WAS a choice) but, at the same time, I think a lot of people in my situation might have felt like there was no point in being sober. I think I was coming from a place of complete devastation and desperation.

You are dealing with a lot. I'm sorry you're feeling so stressed and lonely. For people like us, it makes sense that that kind of desperation can lead us back to drinking. But you have 20 years sober. That time counts. You know what you need to do. You can see the bad consequences coming. You can side step them all. You've had a slip up; at least you know for sure you can't drink! No more internal struggle over "Can I moderate?!" Go back to your sobriety, to the good things in your life. Only from that place can you build up your life again. You deserve good things. Sending you a hug.

I hope you get to read this expression of sincere gratitude for your genuine empathy and the encouragement you have given here. I vowed to quit drinking January 1 and for a couple days I did. And again February 1. And February 14. And March 1. Then I quit for a whole week in April! Then I quit May 15 and am still sober here on June 7 - I am on day 24. I am struggling very hard to not drink... I am facing the same financial, vocational, personal and parenting challenges that I faced back when I started drinking in November 2015. (I did not expect six months of drinking to make any of those things get any better!). I craved alcohol at three major points last week, and on Saturday I had both shoes on and was heading out the door to the liquor store. A friend returned my call as I reached for the doorknob (no lie) and I ended up taking some Ativan and going to sleep after we spoke. As Friday approaches here, and knowing I won't have the kids past Wednesday night, I know I will feel a massive desire to drink at that point. I can feel the craving sensations building up in my teeth and gums and face - even in my "brain" like a dull ache - I can feel the desire to drink building.

I know if I drink I won't be able to keep any promise or intention to moderate aka to "drink only on Fridays" or "have a few on Thursday then go out of Friday". I think if I drink I will again be drinking 8 or so drinks daily and possibly even more on a Friday or Saturday night with the odd "guilty night" off. On my current meds for blood pressure, cholesterol and bipolar disorder, drinking this much is EXTRA dangerous (and stupid). 50+ drinks per week is also four times the recommended maximum and is dangerous by itself.

I really wish I could just get a nice glow from two or three and stop like 'regular people', and not need alcohol every single night.

When I drink now, it's worse than before. Once I crack a beer or pour a whiskey (or both) I seem to have this unusual 8 drink MINIMUM! How I stop regularly after that amount? I have no idea. I am surprised that I can stop at all at that point. I think I am stopping just so I can make it to work in the morning and still be functional. It seems like I "need" or crave this minimum amount of alcohol in my system.

Drinking is not safe for me. Moderation is unlikely. Going off meds that work well for me just so I can "see" if alcohol will affect me more "normally" is just insane. It should be a simple decision.

Hey, sounds like you have pressures on all sides right now. Especially with the BPD (I understand that to an extent). The way you're drinking is how I drank and I am an alcoholic. I would really encourage you to ask for help. AA is free and easy to get to. AA saved my life even if it seems like a "drastic choice". You don't have to do it forever, but the people there will be able to help right now. Many people in AA have dealt with the problems you're having and were able to stay sober. They can give you advice as well as support. You do not have to do this alone. With help, it can get so much better. My life is totally different now. I dont experience the insanity and loneliness anymore. I do NOT have cravings for alcohol and I am fine being around it. I can actually check my bank account and open bills. I have relationships with my family. Please help yourself by asking for help! I'll be thinking of you!

i was googling "can one become an ex AA ?" and landed on this article and then tead your comments and Erob's.

I echo what Erob is saying : I find it amazing that you've managed to stay sober for 20 years. it means you have a key that works. it opened the door to your sobriety world. Now you left this world. But you still have the key to the door. Use the key, maybe it will open the AA world. In there you will find many similar to you, who will understand you, and who will listen to you.

What we all know is that all people have challenges in their lives in varying degrees of severity: We also know there is not one single common solution to all the challenges. Sometimes the solution is to understand the root of the problem and hence elimimate it. Some other times, the solution is to deal with the consequences of the problem and hence contain it. Both work.

I don't think there is anyone who can demonstrate that one solution is better than the other, as long as the problem is addressed

I am an alcoholic and I've been sober for about 8 months. i had a couple of relapses. the most recent being Iast week. This time though my relapse didn't drive me miserable. Obviously I am not happy with myself, but also i am not scared of myself: Mostly because i accept that i am a human who's immensely capable of erring. And thar I am a human who has an undeniable right to try as much as he needs and as long as he needs to find his path.

i am not overly concerned with the neural pathways reversibility and permanent dopamine levels handicap and what have you. These are intelligent words written in an interesting article.

In all humility, what matters is agreeing that there is a problem (you do), having a desire to solve it (you have) and working to address it (you already started). AA is one of the successful ways just to do that.

i apologise for refering to myself so often, for offering my unsolicited opinion and i wish you the best of luck.

Hi Northern Guy, You do know better. But it is possible that you're letting your excuse get the better of you because it is easy. I would suggest finding your local SMART Recovery meeting. It is free, an abstinence-based program that focuses on the science of the brain and self-empowerment. It does not follow the antiquated disease model, nor relies on a higher power, or places labels on people like 'alcoholics'.

It is a refreshing group of people that help and share with each other. They use tools to recognized how your cognitive behaviors could have shifted or been led to addictive behavior. You may also find other behaviors that are addictive as well. It will help you recognize what is critical in life and focuses towards recovery that is not requiring you take in meetings for life nor have a sponsor monitor your every step in life. Self-empowerment is refreshing as it puts you in control of your life. They have great free tools on the SMART Recovery website that is also extremely helpful. However, I suggest that you hit a few meetings, retrain that brain, meet up with the reality why people drink or have other addictive behaviors. SR believes that you do get better and can quit the meetings at some point. It is all entirely up to you and your own personal empowerment. And if life throws its challenges at you it is okay to come back and share your challenges.

At the end of the day, being 20 years clean, you do know better. However, your hierarchy of values may have gotten a little skewed.